Managing \u27shades of grey\u27: a focus group study exploring community-dwellers’ views on advance care planning in older people

Background: Community-dwelling consumers of healthcare are increasing, many aging with life-limiting conditions and deteriorating cognition. However, few have had advance care planning discussions or completed documentation to ensure future care preferences are acted upon. This study examines the awareness, attitudes, and experiences of advance care planning amongst older people and unrelated offspring/caregivers of older people residing in the community. Methods: Qualitative descriptive research, which included focus groups with older people (55+ years) and older people’s offspring/caregivers living in an Australian city and surrounding rural region. Data was analysed using an inductive and comparative approach. Sampling was both convenience and purposive. Participants responded to web-based, newsletter or email invitations from an agency, which aims to support healthcare consumers, a dementia support group, or community health centres in areas with high proportions of culturally and linguistically diverse community-dwellers. Results: Eight focus groups were attended by a homogenous sample of 15 older people and 27 offspring/ caregivers, with 43% born overseas. The overarching theme, ‘shades of grey’: struggles in transition, reflects challenges faced by older people and their offspring/caregivers as older people often erratically transition from independence and capacity to dependence and/or incapacity. Offspring/caregivers regularly struggled with older people’s fluctuating autonomy and dependency as older people endeavoured to remain at home, and with conceptualising “best times” to actualise advance care planning with substitute decision maker involvement. Advance care planning was supported and welcomed, x advance care planning literacy was evident. Difficulties planning for hypothetical health events and socio-cultural attitudes thwarting death-related discussions were emphasised. Occasional offspring/caregivers with previous substitute decision maker experience reported distress related to their decisions. Conclusions: Advance care planning programs traditionally assume participants are ‘planning ready’ to legally appoint a substitute decision maker (power of attorney) and record end-of-life treatment preferences in short time frames. This contrasts with how community dwelling older people and offspring/caregivers conceive future care decisions over time. Advance care planning programs need to include provision of information, which supports older people’s advance care planning understanding and management, and also supports offspring/caregivers’ development of strategies for broaching advance care planning with older people, and preparing for potential substitute decision maker roles. Development and integration of strategies to support older people’s decision making when in the ‘grey zone’, with fluctuating cognitive capacities, needs further consideration. Findings support an advance care planning model with conversations occurring at key points across a person’s lifespan

Religious leaders\u27 perceptions of advance care planning: a secondary analysis of interviews with Buddhist, Christian, Hindu, Islamic, Jewish, Sikh and Bahai leaders

Background: International guidance for advance care planning (ACP) supports the integration of spiritual and religious aspects of care within the planning process. Religious leaders’ perspectives could improve how ACP programs respect patients’ faith backgrounds. This study aimed to examine: (i) how religious leaders understand and consider ACP and its implications, including (ii) how religion affects followers’ approaches to end-of-life care and ACP, and (iii) their implications for healthcare. Methods: Interview transcripts from a primary qualitative study conducted with religious leaders to inform an ACP website, ACPTalk, were used as data in this study. ACPTalk aims to assist health professionals conduct sensitive conversations with people from different religious backgrounds. A qualitative secondary analysis conducted on the interview transcripts focussed on religious leaders’ statements related to this study’s aims. Interview transcripts were thematically analysed using an inductive, comparative, and cyclical procedure informed by grounded theory. Results: Thirty-five religious leaders (26 male; mean 58.6-years-old), from eight Christian and six non-Christian (Jewish, Buddhist, Islamic, Hindu, Sikh, Bahá’í) backgrounds were included. Three themes emerged which focussed on: religious leaders’ ACP understanding and experiences; explanations for religious followers’ approaches towards end-of-life care; and health professionals’ need to enquire about how religion matters. Most leaders had some understanding of ACP and, once fully comprehended, most held ACP in positive regard. Religious followers’ preferences for end-of-life care reflected family and geographical origins, cultural traditions, personal attitudes, and religiosity and faith interpretations. Implications for healthcare included the importance of avoiding generalisations and openness to individualised and/ or standardised religious expressions of one’s religion. Conclusions: Knowledge of religious beliefs and values around death and dying could be useful in preparing health professionals for ACP with patients from different religions but equally important is avoidance of assumptions. Community-based initiatives, programs and faith settin

SEASONALITY OF BIRD STRIKES: TOWARDS A BEHAVIOURAL EXPLANATION

It is well known that, at least in the Northern Hemisphere, there is a strong seasonal element in the annual pattern of bird strikes. This study undertakes a statistical analysis of an 11year data set collected at Dublin Airport, Ireland. It attempts to identify statistically significant trends in the seasonal trajectories of bird strikes, both in general and in respect of individual species and in comparison with seasonal trends in the abundance of birds generally and at Dublin Airport in particular. Hypotheses relating to the idea of “open” (i.e. intervals of through-put of naïve and young birds) and “closed” (i.e. intervals when throughput is declining or at a minimum) periods are tested. The results are discussed in the context of the probable ability of birds to learn to avoid aircraft. If birds possess a spatio-temporal memory then it is likely that this ability, or the lack of it, may explain some of the observed trends in the seasonal distribution of bird strikes

Online, Continuous Sensor and Method for Curd Moisture Content Control in Cheese Making

A method is provided for improving quality of cheese produced from a milk batch. A light beam from an incident light source impinges onto a surface of the milk batch, and light backscatter is optically detected during a coagulation process and correlated to an optimum cutting time for the milk coagulum. Next, light backscattered from a curd and whey mixture derived from the milk batch during a syneresis process is optically detected and correlated to an optimum syneresis endpoint. At least one of the backscattered light data, optical parameters developed from analysis of the backscattered light data, and whey fat dilution are correlated to at least one of a milk protein %, a milk fat %, a milk total solids content, a milk processing temperature, a curd moisture content, a curd moisture change over time, whey fat content, a whey fat loss, and a final curd yield

Method of Improving Cheese Quality

A method is provided for improving the quality of cheese produced from a curd and whey mixture. The method comprises the steps of monitoring the curd and whey mixture during syneresis processing to collect color data, comparing the color data to a predetermined standard and terminating syneresis when the color meets the predetermined standard or, alternatively, analyzing the color data obtained to generate kinetic parameters that can be used to predict the end point of syneresis to improve control of curd moisture content

Design and Fabrication of Coplanar YBCO Structures on Lithium Niobate Substrates

YBa2Cu3O7-δ (YBCO) with low RF losses has been successfully deposited onto lithium niobate (LNO) to improve the performance of electrooptic Mach-Zender modulators. Epitaxial, c-axis oriented superconducting YBCO thin films have been grown on X-cut LNO single crystals with a yttria-stabilized zirconia (YSZ) buffer layer by RF magnetron sputtering. This buffer layer is needed to obtain good superconducting properties of the YBCO grown. Numerical tools have been developed to analyze CPW structures based on YBCO/YSZ/LNO trilayers, and they indicate that YSZ thickness has to be kept to the minimum necessary for good YBCO growth. With this restriction, the RF losses of YBCO/YSZ/LNO samples have been measured. The results from these measurements are used to quantify the performance enhancement in a Mach-Zender modulator using YBCO electrodes

Effects of superovulated heifer diet type and quantity on relative mRNA abundances and pyruvate metabolism in recovered embryos.

This study investigated the effects of quantity and type of diet fed to superovulated donor heifers on molecular and metabolic indices of embryonic development. These effects included the relative abundances of mRNAs for the alpha 1 subunit of Na/K-ATPase and the antioxidant enzyme Cu/Zn-SOD, as well as pyruvate utilization in bovine morulae and blastocysts developed in vivo. Heifers were fed a daily ration of either grass silage and a citrus-beet pulp-based concentrate or grass silage and a barley-based concentrate for 116 days, both at 3 kg per day or ad libitum. In embryos derived from heifers fed the pulp-based diets, the relative abundances of the transcripts were not affected by either day of collection or quantity of diet. In embryos derived from heifers fed the barley-based diets, the relative abundances of the Na/K-ATPase transcripts were also not changed by these main effects, while the relative abundances of the Cu/Zn-SOD transcripts were affected by day of collection and by the quantity of diet. Pyruvate metabolism was affected by day of collection, and was significantly increased in day 8 embryos compared with day 7 and day 6 embryos. Diet quantity did not affect pyruvate utilization, whereas diet type did increase pyruvate metabolism in the barley group when compared with the pulp group. The results of this study show for the first time that molecular and metabolic variations may exist in embryos derived in vivo and developed in donor heifers on nutritional regimens differing in type and quantity. Differences in embryos collected on different developmental days may be attributed to varying cell numbers. Alterations in the relative abundances of the Cu/Zn-SOD transcripts and pyruvate metabolism caused by the quantity of diet fed to the donor animal were likely to have been due to alterations in metabolic end products that accumulate in reproductive tract fluids, whereas differences in embryonic metabolism caused by type of diet are related to the composition of the diet. These findings characterize embryos produced in vivo at the molecular level, indicating that the molecular markers used in the present study can differentiate between populations of embryos produced under different nutritional regimens and determine conditions conductive to the production of good quality embryos

Improved outcomes in stroke thrombolysis with pre-specified imaging criteria

Background: A 1995 National Institute of Neurological Disorders (NINDS) study found benefit for intravenous tissue plasminogen activator (tPA) in acute ischemic stroke (AIS). The symptomatic intracranial hemorrhage (SICH) rate in the NINDS study was 6.4%, which may be deterring some physicians from using this medication. Methods: Starting December 1, 1998, patients with AIS in London, Ontario were treated according to NINDS criteria with one major exception; those with approximately greater than one-third involvement of the idealized middle cerebral artery (MCA) territory on neuroimaging were excluded from treatment. The method used to estimate involvement of one-third MCA territory involvement bears the acronym ICE and had a median kappa value of 0.80 among five physicians. Outcomes were compared to the NINDS study. Results: Between December 1, 1998 and February 1,2000, 30 patients were treated. Compared to the NINDS study, more London patients were treated after 90 minutes (p\u3c0.00001) and tended to be older. No SICH was observed. Compared to the treated arm of the NINDS trial, fewer London patients were dead or severely disabled at three months (p=0.04). Compared to the placebo arm of the trial, more patients made a partial recovery at 24 hours (p=0.02), more had normal outcomes (p=0.03) and fewer were dead or severely disabled at three months (p=0.004). Conclusions: The results of the NINDS study were closely replicated and, in some instances, improved upon in this small series of Canadian patients, despite older age and later treatment. These findings suggest that imaging exclusion criteria may optimize the benefits of tPA